Name *

First Name

Last Name

Do you have any history of pancreatitis? *

Yes

No

Are you currently pregnant or breastfeeding? *

Yes

No

Do you have a personal or family history of medullary thyroid carcinoma or Endocrine Neoplasia Syndrome type 2? *

Yes

No

Do you have any history or current problems with unstable mental health, depression, or eating disorders? *

Yes

No

Do you have a history of kidney or liver concerns? *

Yes

No